Closure of Septal Perforation
Russell W.H. Kridel
INTRODUCTION
The presence of a nasal septal perforation, regardless of etiology, can cause significant functional, structural, and emotional consequences to the patient. Fortunately, the majority of these perforations can be closed surgically, providing that the evaluating physician does not delay surgical repair and allow the perforation to enlarge beyond the possibility of closure. It is important to emphasize that if a surgeon does not repair perforations on a routine basis, a referral to an experienced surgeon is essential as the success of the surgery is directly related to the experience of the surgeon. The success of the repair of the perforation is also related to the size of the defect and its orientation, amount of septal mucoperichondrium remaining, degree of scarring, and whether there is metaplasia or inflammation of the mucosa.
From a technical standpoint, the surgical repair is complex and tedious. The perforation represents a partial absence of three distinct layers of tissue, each of which requires closure and/or grafting. Further, the majority of suturing is performed within the narrow confines of the nasal cavity, and inadvertent enlargement of the perforation can occur easily, especially when the remaining septal flaps are thin, adherent, and friable (Fig. 24.1). Many techniques have been described in the repair of septal perforations; in my experience, the absolute best results are achieved through bilateral mucosal flap development and advancement with the interposition and anchoring of a connective tissue graft between the flaps.
HISTORY
A comprehensive past medical history of all organ systems is performed in all patients who are evaluated for surgery. Such measures are taken to optimize the general health of the patient and surgical safety. Involvement of the patient’s primary care physician is important in the consolidation of the medical history and current medical conditions. Medical specialists are consulted when necessary for evaluation and management of comorbidities and clearance for anesthesia.
The etiology of a nasal septal perforation can often be determined by taking a comprehensive history. This should include eliciting a history of nasal and/or sinus problems as well as other respiratory and autoimmune medical conditions and the use of over-the-counter and prescription nasal medications. One should also consider work-related, environmental, and social factors as well. Most perforations are either iatrogenic or secondary to recreational use of cocaine. If no direct cause can be determined, a full evaluation, sometimes including a soft tissue biopsy, is needed to rule out the rare occurrence of Wegener’s granulomatosis or the even rarer event of nasal-type extranodal NK-/T-cell lymphoma (NKTCL).
With regard to iatrogenic injury, the most commonly relayed history describes an antecedent septoplasty in which contiguous areas of the septal mucosa were torn on both sides, regardless of the presence or absence of intervening septal cartilage. Another common cause is the use of cautery for epistaxis in similar areas on
opposing sides of the septum. Bilateral balloon nasal packing is also well known for its ability to compromise the blood supply of the mucoperichondrium and lead to a large perforation.
opposing sides of the septum. Bilateral balloon nasal packing is also well known for its ability to compromise the blood supply of the mucoperichondrium and lead to a large perforation.
 FIGURE 24.1 A septal perforation is a localized absence of the three layers, the right and left layer of mucoperichondrium septal flaps and the intervening septal cartilage. |
Additional etiologies include facial trauma resulting in substantial nasal fractures or septal hematomas, self-induced trauma from nose picking as well as placement of a foreign body (e.g., button battery) in the nose. The chronic use of nasal spray, both vasoconstrictive and anti-inflammatory, has been implicated as a causative factor. The use of cocaine has increased significantly as a major cause of septal perforation due to the intense vasoconstriction caused by the drug combined with the adulterated chemical irritants used as fillers. Chronic use of cocaine can totally destroy the mucosa of the nasal cavity creating intranasal stenosis and irreparable scarring.
PHYSICAL EXAMINATION
A comprehensive examination of the head and neck is performed on all patients as incidental and significant medical conditions not related to the consultation may be discovered. With regard to the analysis of a nasal septal perforation, a complete diagnosis cannot be made until all crusts have been removed and decongestion of the turbinates has taken place so that the entire nasal septum can be visualized. Examination of a patient with a deviation of the septum and enlarged turbinates is difficult, and a posterior septal perforation may be missed. When a septal perforation is noted, its circumference and relative position should be documented. An ominous sign exists when there is crusting not only around the edge of the perforation but all over the mucosa of the nasal septum and turbinates. Such a finding is seen more often in patients with causes suggestive of a granulomatous process or vasculitis. Findings of overall crusting in a cocaine user or in a patient with a granulomatous process make the prognosis for long-term operative success guarded and usually reflect a metaplasia of the normal respiratory epithelium to a fibrotic nonfunctioning epithelium.
The septum should be palpated with a cotton-tip applicator to identify the presence of cartilage between the mucosal flaps and to determine whether cartilage extends close to the edges of the perforation (Fig. 24.2). There is usually very little cartilage left in perforations that have occurred following septoplasty, which makes dissection of the flaps more difficult. If I find extensive inflammation and/or swelling of the membrane or see synechiae or collapse of the nasal cavity, I definitely consider an ongoing disease process or the active use of cocaine. Previous cocaine use may result in a clean-edged perforation with cartilage present almost all the way to the edges of the perforation. The more inflamed mucosa and crusting there is around a perforation, the more I am suspicious of a generalized process such as continued abuse,
noxious industrial environment, or subclinical soft tissue infection/irritation. Marked inflammation and crusting should be treated with cultures, antibiotics, and local emollients prior to any surgical intervention.
noxious industrial environment, or subclinical soft tissue infection/irritation. Marked inflammation and crusting should be treated with cultures, antibiotics, and local emollients prior to any surgical intervention.
 FIGURE 24.2 A cotton-tipped applicator is used to palpate the septum around the perforation to see if any cartilage remains, which is not likely if the patient has had a previous septoplasty. (©Russell W.H. Kridel, MD. Used with permission.) |
 FIGURE 24.3 Endoscopic view of a septal perforation taken from the right nasal vestibule with a ruler inserted on the opposite left side to measure the size of the perforation. (©Russell W.H. Kridel, MD. Used with permission.) |
When evaluating a septal perforation (Fig. 24.3), the dimension of the perforation is a helpful determinant for the success of repair. However, it is not the absolute size of the perforation that is as important as the proportion of septal membrane remaining, especially in the vertical dimension. For example, a 1-cm perforation in a young child could be much more difficult to repair than a 2-cm perforation in an adult.
The external nose is evaluated for any evidence of a saddle deformity secondary to loss of dorsal support with a large anterior septal perforation or an active disease process. In such cases, surgical plans can be made for dorsal augmentation simultaneous with repair of the septal perforation. Evaluation and documentation of the configuration of the bony nasal pyramid is of importance in both traumatic and nontraumatic cases and may be adjusted at the time of surgery as well.
INDICATIONS
Bleeding, crusting, whistling, and nasal obstruction are indications for surgery as long as the perforation is not too large to repair. Asymptomatic septal perforations do not require surgery. The more posterior the perforation, the fewer the symptoms.
CONTRAINDICATIONS
Patients who are still using cocaine, unrelenting nose pickers, and those with underlying disease etiologies are not surgical candidates. Perforations that extend all the way to the nasal dorsum are almost impossible to repair, unless there is some small cuff of membrane to which the inferior advancement flap can be sewn. Similarly, perforations that extend all the way down onto the floor of the nose are technically difficult.
Silicone nasal buttons may be helpful in patients with a large perforation that cannot be closed surgically. Large defects usually require custom designing of a larger internal button. Although septal buttons are helpful in patients who cannot undergo surgical interventions, they can cause the perforation to enlarge, must be periodically removed for cleaning, and often worsen the patient’s feeling of obstruction due to the bulk they add to the nasal airway.
PREOPERATIVE PLANNING
The major goals of surgery are to close the perforation and restore normal function and physiology to the nose. Many different techniques have been described for closure, but only those that use intranasal advancement flaps are able to achieve normal nasal physiology. However, if extensive scarring or metaplasia of the existing septal flaps is present, it may be impossible to totally restore physiologic function. Other methods that use skin grafts or buccal mucosal grafts may be effective in closing the perforation but unfortunately leave the patient with a dry nose that continues to crust because the respiratory epithelium is not restored.
SURGICAL TECHNIQUE
Surgical Approach Considerations
Although treatment of nasal septal perforations can be performed endonasally, an open approach has multiple advantages that make this the technique of choice. The open approach affords superior access to all dimensions of the perforation and provides a field without the distortion that normal intranasal retraction causes. This technique also preserves the anterior septal blood and lymphatic supply and may even improve the viability of the nasal advancement flaps. Better stated, the small transverse columellar incision is a small price to pay for the improved access to the perforation with improved outcome from the surgery.
One of the minor disadvantages of the open approach is that the medial crura are totally dissected away from each other and from the septum. The fibrous connections between the medial crura and the septum and the overlying skin are supporting attachments that normally help to preserve tip projection. It is incumbent upon the surgeon to reconstitute this support structure after the perforation is repaired; otherwise, tip-drop will almost invariably develop and create a cosmetic deformity that was not present prior to the surgical procedure. The medial crura can be sewn back together with interrupted sutures, and sometimes, a columellar strut must be placed between the medial crura to further support the nasal tip.
Bilateral bipedicled floor and dorsal (from under the upper lateral cartilages) mucosal advancement flaps require mobilization and borrowing of septal mucosa in the vertical dimensions. The upper lateral cartilages are separated from the septum, and as the membrane that is still attached to the upper lateral cartilages is pulled down for attempted closure, the upper lateral cartilages themselves will also have a tendency to be pulled inferiorly. To avoid the tendency to develop a pinched appearance of the middle one-third of the nose, spreader grafts and onlay grafting materials may be placed so as to maintain the contour of the nasal dorsum. Likewise, as the mucosal defect is closed and the bipedicled flaps are pulled into position, a certain amount of tension is placed on the mucosa of the caudal septum and the medial crura, sometimes producing a cephalad rotation of the nasal tip. If the patient has a ptotic tip, these maneuvers will actually help to improve the esthetic result. However, if the patient’s nose is already overrotated or foreshortened, the problem may be worsened by the repair, and corrective methods will have to be added to the procedure to counteract these effects.
Interposition Grafts
The use of an interposition graft is necessary for successful repair. Traditionally, temporalis fascia has been used as a template for overlying mucosal tissue migration and vascularization due to its extremely thin nature and very low metabolic requirements. Additionally, the graft maintains a barrier between the corresponding repaired flaps during the healing process and decreases any risk of the incision breaking down with subsequent reperforation. If temporalis fascia is used for reconstruction, a horizontal scalp incision is made with care to bevel the incision so as to remain parallel to the hair follicles. The scalp is retracted, and the dissection is carried down to the deep temporalis fascia with wide undermining. The dimensions of the harvested graft must be significantly larger than the perforation so that its edges go far beyond the perimeter of the original perforation. The surgeon should take into account the possibility of enlargement of the perforation due to manipulation and dissection of the flaps. A large piece of temporalis fascia (5 cm) is harvested. A mastoid type pressure dressing is applied after complete hemostasis is achieved.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
